Provider Demographics
NPI:1285815662
Name:CHANDRIA LYNN JOHNSON MD PA
Entity Type:Organization
Organization Name:CHANDRIA LYNN JOHNSON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHANDRIA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-936-1316
Mailing Address - Street 1:P.O. BOX 266
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32572-0277
Mailing Address - Country:US
Mailing Address - Phone:850-983-2238
Mailing Address - Fax:850-936-5808
Practice Address - Street 1:5950 BERRYHILL MEDICAL PARK DR
Practice Address - Street 2:SUITE B
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570
Practice Address - Country:US
Practice Address - Phone:850-983-2238
Practice Address - Fax:850-936-5808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90117207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAJ019Medicare PIN